| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,907 |
801 |
$134K |
| D1120 |
Prophylaxis - child |
3,773 |
3,620 |
$121K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
907 |
383 |
$102K |
| D1206 |
Topical application of fluoride varnish |
4,084 |
3,915 |
$84K |
| D0120 |
Periodic oral evaluation - established patient |
3,259 |
3,118 |
$75K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,580 |
1,465 |
$45K |
| D7140 |
Extraction, erupted tooth or exposed root |
659 |
330 |
$41K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
411 |
212 |
$34K |
| D0272 |
Bitewings - two radiographic images |
1,578 |
1,506 |
$26K |
| D1510 |
|
162 |
110 |
$26K |
| D0330 |
Panoramic radiographic image |
476 |
466 |
$22K |
| D1351 |
Sealant - per tooth |
719 |
247 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
714 |
702 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
315 |
191 |
$19K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
134 |
88 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
748 |
677 |
$8K |
| D1110 |
Prophylaxis - adult |
239 |
236 |
$8K |
| D0274 |
Bitewings - four radiographic images |
272 |
255 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
158 |
143 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
314 |
159 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
96 |
89 |
$2K |